Disease in bone [electronic resource] : and its detection by the x-rays

H. K. LEWIS,
136 GowcR Str::et.

DISEASE IN BONE AND ITS
DETECTION BY THE X-RAYS

MACMILLAN AND CO., Limited

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THK MACMILLAN COMPANY

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TORONTO

DISEASE IN BONE

yind its T)etection by the X-I^ays

BY

EDWARD W. H. ^SHENTON

jM.K.C.S., eng., I..K.C.]'., LOND., SEN. SUKG. RADIOGRAl'HER,

guy's hospital,

iriTH ILLUSTRATIONS

MACMILLAN AND CO., LIMITED
ST. MARTIN'S STREET, LONDON

1 91 1

1^3

RiCHAKU Clav and Sons, Limited,

BREAD STREET H11.L, E-C, AN'1>
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PREFACE

This small work constitutes an attempt to record
facts which radiographic experience, extending over
some fourteen years, has made me regard as funda-
mental in diagnosis.

They are facts which are not generally known,
or I venture to think that surgeons would make
more use of the X-rays, and not merely relegate
them to the detection of coarse and obvious lesions.

So many diseases, clinically alike, are radio-
graphically different — as instances, (i) Tubercle
and osteo-arthritis, (2) Malignant disease and
chronic inflammatory trouble in the shafts of long
bones. Several examples have come to my notice
in which mistakes made in these conditions might
have been avoided by the skilful use of the X-rays.
I would lay emphasis on the word " skilful," for
the prevalent method of getting a patient photo-
graphed with X-rays by anyone in possession of an
X-ray apparatus is, in my opinion, worse than
having a patient's chest examined by someone
whose only qualification to ofBce is the possession
of a stethoscope.

The absurdity in this latter case is too apparent
to need discussion, and yet, in connection with the

vi

PREFACE

former where the diagnostic instrument involved is
infinitely more complex and the initial difficulties
much greater, we are seldom vouchsafed more
information than that the " X-rays did not show,
etc., etc." We most of us only "see the things we
are taught to see," and I venture to predict that in
years to come we shall marvel at the very obvious
pathological conditions that we are missing to-day
for want of looking for them.

I would further predict that the examination for
varying densities in bone will become a routine
practice in surgical if not also in medical diagnosis.
I have not seen attention called to the various forms
of thinning which are treated of in the following
pages and which accompany many chronic diseases.
Among such I would put alcoholism. No doubt
there are many more, and I hope to be able to add
to the list at a later date ; but the difficulties are
very great from a technical point of view. The
vagaries of the tube ape the conditions themselves,
and considering one is dealing with millionths of
an atmosphere it is scarcely to be wondered at. To
keep the source of A-rays steady is like balancing
an egg on the edge of a sword. The equilibrium
is of a most unstable nature. These remarks apply
to the newer forms of A-ray apparatus, such as the
" Snook," which at their best are so much better
than the older type of coil and interrupter, but
which involve more risk to tubes and greater skill
in management.

PREFACE

vii

In selecting radiograms I have endeavoured to
obtain those which I consider typical, and such as
represent the usual work of a well-equipped X-ray
department, and none have been printed for their
photographic excellence. Opinions differ as to
what is excellence in this respect. The less an
individual has studied the subject the more he
favours the black and white picture. Conversely,
the better informed he is the less he strives after
contrast and the more value he attaches to detail
and the faithful reproduction of the relative densities
of the tissues he is dealing with. It would seem
reasonable to suppose that those radiograms are best
which most faithfully represent the conditions
which are present, and to use artifice to obtain a
brilliant photograph of a tubercular joint seems to
me to be attempting a piece of childish self-decep-
tion. This is where the layman has the advantage
of the medical man because he so often takes
" clearer " photographs. These facts may seem
elemental, but they are apparently common know-
ledge only to those who work with the rays. The
illustrations in the following pages are from purely
unfaked photographs, and the blocks are true
reproductions of these.

On account of the number of these blocks I
have adopted a large type and wide margin, thereby
ensuring that illustrations shall be near the passages
that refer to them.

It will be noticed that joint disease is rather mixed

viii

PREFACE

up with bone disease, but my excuse is that the
radiographer does not, strictly speaking, see
the joint surfaces, and bases his conclusions on
the adjacent bone tissue.

No attempt has been made to completely cover
the somewhat vast ground suggested by the title of
this book, and many common conditions are con-
spicuous by their absence. In some cases this is
due to w^ant of sufficient evidence, in others to the
fact that the ^-rays are not as suitable as other
clinical methods of examination. One omission I
must just mention — syphilitic disease. About this
I hope, later, to be able to give some helpful notes,
but at present they are not ripe for publication.

I w^ould like to take this opportunity of thanking
many friends who have helped me directly or in-
directly in the compilation of these notes. To
my colleagues, Drs. Morton and Jordan, I am in-
debted for many kindnesses, and to the staft of
Guy's Hospital I owe more than I can acknowledge
here, but for nothing am I more grateful than their
attitude towards the whole subject of J^-ray work.
In my opinion it has raised radiography from a
branch of photography to a branch of practical
medicine. As a pioneer I might have had the
rough time pioneers look for, but my way has been
considerably smoothed by their generous encourage-
ment.

CONTENTS

Introductory Remarks
Inflammation in Bone
Tubercular Disease .
Osteo-Arthritis
Growth in Bone .
Osteo-Malacia .

ix

I

LIST OF ILLUSTRATIONS

I'AGE

Fi,;. I. Specimen of apparently good radiogram of knee-joint, which in

"reality would be useless for demonstrating any but very gross lesions.
It is quite unsuitable for observing atrophic changes. Compare this

with Figs. 28 and 33 3

Fig. 2.— Genu Valgum. Typical rachitic bones 7

Fig. 3. — Bad fracture in atrophic bone (probably alcoholic) .... 9
Fig. 4.— Typical example of Mr. Arbuthnot Lane's method of treating

fractures surgically. The entire absence of callus is noticeable . . 12

Fig. 5. — Abnormal growth of callus round fibula 13

Fig. 6.— Chronic periostitis of tibia and fibula. Observe lines of mineral

matter parallel to shafts of bones 15

Fig. 7. — Chronic periostitis of tibia. Observe line of newly-formed bone

parallel to shaft on inner side 16

Fig. 8. — Simple abscess just above epiphysial line of lower end of tibia.
The general definition of the surrounding bone tissue would negative
tubercle 1 7

Fig. 9. — Fron view of Fig. 8 i8

Fig, 10. — Chronic osteitis. The upper portion of the bone is sclerotic and
the disease is quiescent as evidenced by the great density. The lower
portion shows the thinning due to the active inflammation. Midway is
an abscess cavity with a sequestrum 19

Fig. II. — Small abscess cavity in shaft of tibia. Probably active and con-
taining bone debris 20

Fig. 12. — Results of chronic osteitis, probably healed. Old abscess cavities

and much sclerotic change causing extreme density 21

Fig. 13. — Old abscess cavity in head of humerus; disease quiescent or

extinct 22

Fig. 14. — Showing usual signs of chronic osteitis. Destructive and repara-
tive processes going on side by side ; spindle-shaped piece of dead bone
being exfoliated shown by arrow . . . 23

Fig. 15. — Chronic osteitis and sequestrum 24

Fig, 16. — Necrosis of terminal phalanx of great toe, showing ragged appear-
ance of the edges of the eroded bone 2 ";

Fig, 17. — Result of acute osteo-myelitis in young bone. The ulna has dis-
appeared, but a new bone is growing in the old periosteum. In the
meantime the radius has grown longer than the ulna 26

Fig. 18. — Sequestrum in first phalanx of second finger .... 27

Fig. 19, — Root of tooth being eroded by unerupted tooth .... 28

Fig. 20.— Clear area indicating absorption of root of central incisor. All

the front teeth are crowns fitted to stumps 28

Fig, 21. — Showing light normal area around lower unerupted wisdom . . 29

xi

xii

LIST OF ILLUSrUATIOXS

Fig. 22.— N

22.— Normal appearance of teeth Nolo ili^ , ''A'^e

m its surrounding clear area uncrupted wisdom

Fic:. 23.-Active tubercle in tarsus, an early stage ' ' ' ' * ' 3'

Fig. 25.— Congenital dislocation of right hip ' " • • ■ 36

'■'%t;^e^nro;?xtinS °f -gSest's disease :'

''"•^^;;;^S:"^^l^S^^,^--,^^^7en se^ond'and* third lumbar
the condition to be cured ^^"^"y °f t'^e bone conclusively proves

Fig. 2S.-A normal hip joint showing the diagnostic line ^ " '
Fig. 29.— Rheumatoid arthritis in active stacrp Ar^f„ ,1, 1 • .'

ning and the emphasising of tlfe ca^cello^s tissue ^'^^^'^^^--^^--l- ^hin

Fig. 30.— Rheumatoid arthr-itis in active stage • • ■ • 4

difin"^;Sf °' ^h-'-'^S the- typical outlining" and" fine

'"''"lippi;?'''':"'''':"''^. ^-'-'y h->'hy- ^"ch

^'^''DSen-i'^' TC^'''''"^■^ ''°"f '^^"^'^^ possibly by old fracture of
patella. The change is not unlike osteo-arthritis in many respects

i'lG. 34- -Atrophic changes in bone of amputation stump
^'"-^i^^:'^''':''"'', _ The hook turns away from the

°[ ^'''''^ ^^"'-^ accompanied by some enlareement of'

condition. The^^!Hk:"SroL-\;:^:iy'T::^ tr^'r-:^! s S: -

bone IS very characteristic of exostosis . . ^'"^

Fig. 3S.-Exostosis of lower end of femur from a case of multiple exostosis "

iZv Iv.vlc ^" =»PP'-^^'-^"'--^' t"'-'illy diflerent from the regular

l.on) layeis seen in chronic periostitis. (Mr. Mower White's case )

!• IG. 40. -Sarcoma, front view of Fig. 39. (M,-. Mower White's case.)

37
40

41

42

46
47

51

52

53
55

5S

59

60
61

62
63

^"^■nt!;.r''^".''°\V''-'' sai-coma of rapidgrowth diagnosed as greenstick fracture

pi evious to A'-ray examination. No signs of ossification . . 66
Fig. 43— Endosteal sarcoma in child. Note the irregular spotty appearance 67

ritnnlP'fT"'"^'''"'''--';^,"'''"?^^ "^'^ rarefaction accompanied by new
deposit of bone in neighbourhood of compact tissue. The bone would
appear to be strong on account of the density of the mineral matte. 70

'''■nt.'rn":af boVe'blgjL'''^- ^'"""^ -h^re disease leaves off and fairly

^'''■nttm^''''^?r'^ '""f knee-joint. The lower margin of the

minelal mailer '"^ " ^""^ °^ absorption of

DISEASE IN BONES

INTRODUCTORY REMARKS

Those changes which take place in bone,
whereby its condition is altered from one of health
to disease, are accompanied by variations in
opacity to X-rays. A decrease in density due to
absorption of mineral matter is a much earlier and
more quickly visible change than increase of
density caused by extra deposition of mineral
matter or new bony growth.

From which it may be gathered that generally
speaking acute bone disease is made evident by
increase of transparency, and chronic disease by
increase of opacity.

Certain pathological conditions in bone are of
course manifested by alteration of contour when
examined by the X-rays, but even these are
usually accompanied by changes in the opacity of
the bony substance. It is therefore mainly to
changes in density that one must look for help in the
diagnosis of disease in bone.

B

2

DISEASE IN BONES

Normal Normal variations in bone density (meaninp; by

variations •' o j

denshy^ ^cnsity opacity to the X-rays) need careful con-
sideration at the outset, for unless the observer
makes himself familiar with these he may be
led into much confusion. Bones increase in
their density from foetal to adult life (or
perhaps it would be more correct to say until
the epiphyses are united), and remain constant
Old age. after this. In old age the bones may appear
denser, but this is mainly due to the lessened
opacity of the surrounding tissues. In like manner
thin people will seem to have denser bones than
stout ones. Constant examination of the human
subject will familiarise the observer with these
normal appearances and enable him to detect the
abnormal more easily.
Variations Meutiou must be made of another variation in
quaikyof thc apparent density, due solely to the X-ray tube.
Arajs. rj.^^^^ which the vacuum is not very pro-
Low nounced, technically known as low tubes, produce

tubes. ,-11 11

a very black image of the bones both on screen
and photographic plate. On the photograph,
although the contrast between bone and back-
ground is very great and the picture on this
account rather attractive to the person who likes
everything "very clear," it will be noticed that
detail is mostly missing ; the effect is more that of
a silhouette than a photograph (Fig. i).
High Tubes of the opposite variety, i.e., the high

tubes, those in which the residual gas has been

INTRODUCTORY REMARKS 3

reduced to a minimum compatible with the
passing of an electric current (N.B. — A perfect
vacuum is impenetrable by electricity), give a

Img. I.— Specimen of apparently good radiogram of knee-joint, which in reality
would be useless for demonstrating any but very gross lesions. It is quite un-
suitable for observing atrophic changes. Compare this with Figs. 28 and 33.

faint grey image upon screen and plate. The
v^ant of contrast betv^een background and bone
makes the picture appear wQzk upon casual
examination, but close observation w^ill show a vast

B 2

4 DISEASE IN BONES

fund of detail which may be of the utmost value
in detecting disease. Generally speaking, a tube
inclined to be high will be of more value than
one of the opposite variety, but it is the part of
the radiographer to suit his tube to his patient,
and the tube will therefore hereafter be considered
as a fixed quantity in discussing the X-rays in
relation to bone disease.
Import- Before leaving the technique there is one other
SmTting fundamental matter to be mentioned. If an
pktufe. unshielded tube is used for screening or radio-
graphing, a much larger picture is produced, always
supposing the size of the plate to be unlimited.
Thus it is quite possible to get a leg showing knee
^ and ankle joint on one photograph, but this is only
done at the expense of definition. The Z-rays,
being rapidly divergent, must of necessity distort an
image as it approaches the margins of the plate ;
therefore in the above case both knee and ankle
will be distorted. This should be borne in mind
when attempt is made to get both hips upon one
plate. The best rays are wasted in the middle of
the plate, and it is usually much better to take
two small plates so arranged that the centres of
the illumination fall about the position of the
Mpon- acetabula. Then again an unshielded tube, like
^u^^"' an unstopped photographic lens, is the cause of
tt"'"" much distortion and fogging, and the use of a
diaphragm as small as the subject will allow is
advisable in every case.

INTRODUCTORY REMARKS 5

If it is essential to take a large plate, that is, get
a large portion of the body into one picture, this is
best done by increasing the distance of tube from
plate and still using the diaphragm. Such a
method makes exposure very long unless apparatus
such as the " Snook " is available.

It should be a fairly easy matter for anyone
acquainted with X-iay appearances of bone to
recognise a departure from the normal. In the ^^.^j^^^^-
investigation of bone disease I would lay gi'^^ter p^o^to-^
stress upon the advisability of X-ray photography
as compared with screening than in any other
branch of X-ray diagnosis. The roughness of the
fluorescent screen, which seldom presents any
hindrance to diagnostic work in a general way,
may do so in the case of bone substance
by J^efFectually obliterating the definition of the
cancellous tissue. The photographic film is much
better suited to this work on account of its fine
grain.

The screen, however, is of paramount import- Use of

^ screen.

ance during the taking of the radiogram, to enable
the radiographer to select the correct view and
adjust the vacuum of his tube.

Passing on to the subject of abnormal variation Precursors

r . . . . . . °^ disease

of density in bone, it will be necessary to consider ^hich

■' - affect

conditions which, not being actually pathological,
are yet often precursors or concomitants of
disease.

Malnutrition in the human subject is accom-

6

DISEASE IN BONES

panied by atrophic changes in bone, and these are
evidenced by increase in transparency to the
Rontgen Rays.
. Malnutrition beine more rife amone the lower

nutrition.

classestnan the well-to-do, it follows that hospital
patients very frequently show this atrophic change,
and their bones are more difficult to discern than
those of the well-nurtured individual, and it is
notable how much more difficult it often is to
distinguish the outlines of a fracture in such a case
when much extravasation of blood at the seat of
fracture has increased the X-ray density of the
surrounding tissues. This malnutrition is well
marked, as would be expected, in many cases of
rickets, but as the patient recovers in this disease

Kachitis. the mineral matter is reinstated, and a rachitic
deformity therefore is not invariably accompanied
by a want of density. As a diagnostic factor this
thinning of the mineral matter is not of much
value in rickets compared with such easily ascer-
tained facts as exaggeration in the normal curves of
the long bones, the secondary curves and enlarge-
ments at the line of junction of diaphysis and
epiphysis. However, as a guide to the progress of
a case of rachitis the rays may be helpfully used for
observing variations of density (Fig. 2).

Anttmia. ^u^iia, froui any cause of prolonged diiration,
will affisct the transparency of the bones as will any
disease in which malnutrition of the body generally
is a prominent feature. An interesting and per-

INTRODUCTORY REMARKS 7

haps unlooked for cause of loss of X-ray density is
found in the case of rest or disuse of the bones of
the limbs. This is a matter of common observation

Fig. 2. — Genu Valgum. Typical rachitic bones.

in any X-ray clinique. A bone set at rest Bones at
atter tracture is a good example of this condi-
tion. A few days are sufficient to bring about
a degree of absorption of mineral matter capable of

8

DISEASE IN BONES

Mal-

union

causing

atrophic

change.

Alropliic
change in
alco-
holism.

Testing
bone
before
operation.

demonstration. I am unable to say that treatment
of fracture by massage or hyperasmia has any
influence upon this appearance, but would expect
to find that atrophic changes were less marked if
not entirely absent.

Cases in which jjnion^of a fracturejias not taken
place show marked diminution indensity — that is,
when they have arrived at the stage at which
efforts at repair have been discontinued. Natur-
ally, previous to this, while an excess of callus is
being thrown out in a vain endeavour to
accomplish fixation of the fragments, an increase
of density may be visible merely from the excess of
bony tissues about the seat of the fracture. A
fractured femur which had resisted all the efforts
of Nature and the surgeon to become united showed
this thinning to such an extent that the bone was
scarcely visible in the radiogram.

A^v^ri£ty_of_th^^ in an X-ray sense

is t£_b£j9uadJii__die_ca^^

It is a common occurrence to see in the bones of
these people a uniform atrophic appearance.
Fractures in these bones are disastrous in their
magnitude, being accompanied by much com-
minution and crumbling (Fig. 3). They also are
slow to unite and unfit for operative measures.
I cannot help thinking in this connection that
before bone operations the surgeon would be well
advised to have the quality of the bone tested in
this way.

Fig. 3. — Bad fraclure in atrophic bone (probaljly
alcoholic).

9

10

DISEASE IN BONES

Callus. The subject of callus formation may be fittingly
considered here.

There is much variation in the X-ray appear-
ance of callus, and as callus is only made visible by
the deposition of mineral matter in its substance,
these variations are mainly due to some abnormality
in the manner of this deposition.

It is a most fortunate fact that early callus is
entirely transparent to the Z-rays ; otherwise we
should not be able to judge the nature and extent
of a bony lesion except just after its occurrence.
As it is, for many weeks we see the exact outline
of a fracture, and sometimes the deposit of mineral
matter is delayed for months.

Average It would be difficult to fix au averap-e time at

time of _

appear- which callus becomes visible to A-ravs : perhaps

ance of J ' r i

callus. three to eight weeks is the normal fluctuation.

Occasionally abnormal formation of callus is met
with ; for example, in connection with an un-
united fracture a great superabundance of callus
may be present, evidently an effort on the part of
Nature to obtain the desired fixation of fragments
at any price.

A small, clean fracture unaccompanied by
displacement conversely will show a minimum of
callus, and whatever is formed is quickly absorbed
as union is effected. The more nearly the fractured
bone is restored to its original shape and the more
complete the fixation of this position the less
callus will be formed, and the less mineralised will

INTRODUCTORY REMARKS 11

this callus be. In fracture successfully treated by
open operation, where perfect position and fixation
has been accomplished, it is unusual to get any
Jt-ray evidence of callus. For many years I have
had the opportunity of examining nearly all the
cases of fracture treated surgically by Mr. Arbuthnot Mr. Lane's

■' ■' cases of

Lane and the entire absence of callus is a constant surgically

' treated

feature. In cases of old fracture and bad com- fractures,
pound fractures callus is usually evident, but in
very much smaller quantity than when treated by
other methods. It would seem reasonable to
suppose that the rapid convalescence and restora-
tion to complete mechanical activity which is so '
noticeable in these cases is due partly to the
elimination of energy expenditure necessary for
the formation and mineralisation of large masses
of callus ; and to the absence of interference of
soft parts around the seat of fracture due to the
pressure of a large unaccommodating mass of bony
material.

An example which Mr. Arbuthnot Lane
has kindly allowed me to reproduce will here
illustrate the absence of callus in a typical case
(Fig- 4)-

A curious abnormality in callus formation is Abnormal

Cell Ills

shown in Fig. 5, and the explanation is not
apparent. I have seen such a condition before
but very rarely. The curious arrangement of
the mineral deposits is noticeable and the history
of definite fracture is missing. Whether the

Flc. 4.— Typical example of Mr. Aibuthnot Lane's method of treating
fractures surgically. The entire absence of callus is noticeable.

12

INTllODl'CTORV REJSIARKS 13

fracture was devoid of clinical signs and the patient
continued to use these bones despite the injury, and
thus an abnormal callus was caused to form, I

Fu;. 5. — Abnormal growth of callus round fibula.

cannot say, but were this the case the constant
working of the broken ends may have had some-
thing to do with the unusual appearance.

INFLAMMATION IN BONE

A CHRONIC inflammation in an early stage — one
of a few weeks' duration unaccompanied by abscess
formation — will rarely give any X-ray indications.
At most a thinning or absorption of mineral
matter is noticeable.
Early In the case of an early chronic periostitis it is

periostitis. ' , , ,

not uncommon tor the X-ray appearances_tq _be-
normal, while clinically the bone is much enlarged.
In a few weeks this thickening will becorne visible
as the mineral matter is deposited. Osteitis being
generally accompanied by more or less periostitis,
may therefore give its first evidence by the
mineralisation of the swollen periosteum.
Periostitis. Looking along the outline of the bone, this
newly deposited mineral matter may be seen
usually in lines running parallel with, but not
touching, the shaft of the bone. Presumably there
are cases of inflamed bone which quickly subside
and leave no trace, to the X-rays, but experience
suggests such cases are rare. For example, a bone
that has been struck suflficiently to cause a tender

14

INFLAMATION IN BONE 15

spot lasting a week, yet not cracked or struc-
turally damaged, may in a few weeks exhibit

I;
I

B

Mbs»>£aaiiafcat...iwKaifc ■ liifta^Yia^ifa^ j

Fig. 6.— Chronic periostitis of tibia and fibula. Observe lines
of mineral matter parallel to shafts of bones.

layers of mineral matter in the periosteum covering
the part which is absorbed again in a few more
weeks. Such thickening and mineralisation of

Fig. 8.— Simple abscess just above epiphysial line of lower end of tibia.
The general definition of the surrounding bone tissue would negative
tubercle.

18

DISEASE IN BONES

the periosteum over a bruised bone may suggest
the callus of a fracture and that some fissure has
been overlooked. It can usually be difi^erentiated

Fig. 9.— Front view of Fig. 8.

Linear tVom callus by the linear arrangement of the bony

mentof laycrs as opposed to the spotty distribution or the

newly- .

formed boue salts in the latter (Figs. 6 and 7). Linear

bone salts. ^^^-T": — i

marks parallel with the shaft of a bone w^hich

presents clinically ^n0^tKer__si^n^^th^^

Fig. io. — Chronic osteitis. The upper portion
of the bone is sclerotic and the disease is
quiescent as evidenced by the great density.
The lower portion shows the thinning due
to the active inflammation. Midway is an
abscess cavity with a sequestrum.

19

C 2

Fig. II.— Small abscess cavily in shaft of lihia. Probably
active and containing bone debris.

20

INFLAMMATION IN BONE 21

size, ar£_stroiig43remir^ inflamma-
tion of some duration. Such inflammation may
have several causes, but as a Jact v^hich con-
clusively puts growth of a malignantnatufe^ouTof

Fjg. 1 2. —Results of chronic osteitis, proljably healed. Old abscess
cavities and much sclerotic change causing extreme density.

courtjl isjiighly^jmpor^aiit, One has in mind

three occasions v^hen this simple observation
determined the diagnoses of three patients
with enlarged shafts to their femurs, each
of whom was supposed to be the victim of

INFLAMMATION IN BONE 23

malignant disease. In one there was a definite
history of traumatism — a kick on the thigh, but in
the other two cases the cause of trouble was more
obscure. It is not always so simple a matter to

Fig. 14.— Showing usual signs of chronic osteitis. Destructive
and reparative processes going on side by side ; spindle-
shaped piece of dead bone being exfoliated shown by arrow.

make a differential diagnosis between infiamma- Differen-
tory and malignant condition as the case of which gnosiTof
Figs. 36, 37, and 38 are the illustrations will 'nflamma-

1 1 lion.

prove in the chapter on growth in bone.

•24 DISEASE IN BONES

Later Subsequently the subject of bone inflamed

bone by other than simple causes will be dealt with,

inflamma-
tion, but for the present it will be better to follow

Fig. 15.— Chronic osteitis and .sequestrum.

up the X-ray appearances of the later stages of
bone inflammation.

Necrosis and abscess formation may with

INFLAISIMATION IN BONE 25

advantage be considered here (Figs. 8, 9, 10, 11,

I2S 13, 14, ^7 ■^^'"'^^ ''^)-

The longer an inflammatory process proceeds

the more easily may the thinning of the mineral

Fig. 16. — Necrosis of terminal phalanx of great toe, showing
ragged appearance of the edges of the eroded bone.

matter and the excavations be recognised. Irregu-
lar hollows with ragged outlines are the rule in
an acute stage, the bone disappearing in much
the same way as a lump of sugar dissolves

IG. 17. — Resull of acute osteo-myelitis in young
bone. The ulna has disappeared, but a new bone
is growing in the old periosteum. In the meantime
the radius has grown longer than the ulna.

26

INFI.AMMATION IN BONE

27

(Fig. 1 6). The cavities forming at this stage,
being filled with bone debris and mineral matter
dissolved from the walls, are not so obvious or
easily recognised as if they were filled with air

or even new growth of a soft nature, or a simple
fluid ; hence one must look very carefully for
them (Fig. 1 1). In one's experience sequestra are Sequestm.
not so frequently found, or at any rate so obvious as
would be supposed. Several examples are, how-
ever, shown (Figs. lo, 14, 15 and i8).

28

The inflammatory process may proceed to com-
plete destruction of the bone and mere pulpiness
remain, which to the rays will show as a greyish
mass with little crumbs of dark material scattered
.through — particles of disintegrated bone. This
appearance is rather rare in simple inflammatory

Fig. 19. — Root of looih
bcinp; eroded hy un-
erupled tooth B.

Fig. 20. — Clear area indicating
absorption of root of cen-
tral incisor. All the front
teeth are crowns fitted to
stumps.

Resolution
of inflam-
mation.

Sclerotic
changes.

condition, and is mostly seen in the chronic
destructive process of tubercle.

In the event of an acute, subacute, or chronic
inflammatory process resolving, the changes in
effect are slow but sure to the rays. There is a
gradual clearing of the image from the absorption
of fluids, a general tendency for the bone to
become more opaque from the redistribution of
mineral matter, gradual intensification of the bone
shadow (evidently sclerotic changes and a de-
positing of extra bony material where the

INFLAMMATION IN BONE 29

mechanical strains of the linib demand support).
A bone recovering from a severe inflammatory
disorder will therefore show many dark lines and

Fig. 21. — Showing light normal area around lower unerupted wisdom.

formation in the periosteum will accompany this
state of affairs and add to the irregularity of the
picture (Fig. 12.) Old cavities will be easily recog-
nisable, as those are very slow to get filled with
X-ray opaque material, and one has seen such
cavities many years after recovery (Fig. 13).

30

DISEASE IN BONES

Where resolution has been delayed, or chronic
suppuration has supervened on an acute osteitis,
sclerotic changes may be seen, accompanied by
disintegration of other portions of the bone, or
one cavity may continue to discharge pus while
surrounding portions of the bone show signs of
Injection rccovcry (Fig 14). Occasionally in such cases

of bismuth . .......

into bone the cavity is injected with some X-ray opaque

cavities. . 1 " 1 •

material such as bismuth in emulsion. This
method is one that Mr. Charters Symonds uses
with much success. The bismuth emulsion is
injected into the cavity with a syringe, and under
slight pressure finds its way into all the ramifica-
tions of the abscess and the extent of the cavity
is thus very satisfactorily shown.
Dental Whilst discussiug the radiographic appearances
tions. of inflammatory conditions of bone, special remark
should be made of dental conditions. The carious
tooth will of course give its characteristic shadow
to the rays, but the dental mirror is obviously more
satisfactory for diagnostic purposes. However,
there is often much conjecture as to the health or
otherwise of the portion of a tooth which cannot
Abscess be seen by ordinary methods. A simple example

at root. 1 r 1 '-r-<i • I

is abscess round the root of a tooth. This makes
itself abundantly evident by a clear area — caused
more by the absorption of mineral matter than by
actual cavity (Figs. 19 and 20). In cases where small
pieces of root have been left behind after extraction
these may usually be seen lying in an apparent

Fig. 22.— Normal appearance of teeth. Note the lower unerupted wisdom in its

surrounding clear area.

31

32 DISEASE IN BONES

halo — the surrounding area of demineraUsed bone
tissue. Around an unerupted tooth (Figs. 21 and 22)
a light area is also present, but this is so shapely and
clearly outlined that once seen it could never be
mistaken for the abnormal and irregular patch
surrounding a septic stump. Larger abscesses in the
jaw do not differ materially in their X-ray appear-
ance from bone abscesses elsewhere.

TUBERCULAR DISEASE

Tubercle in bone manifests itself chiefly by Thinning
undue transparency. Being; a disease in which tissue in

^ . . ° . . tubercle.

mah:iutrition is much in evidence, it is no uncommon
thing to find all the bones of a tubercular subject
less opaque than normal, although no tubercular
bone disease is present. At the site of a bony
lesion all grades of increased transparency are
observable from the slight change of general
malnutrition to the extensive ones of rarefaction,
necrosis or cavity formation.

When the lesion is in the neighbourhood of a Disap-

• • 1 J • • 1 1 pointing

joint additional changes are observable. In an early A'-ray

^ appear-

stage when the synovial membrane alone is affected ^nce of

tubercle.

the appearance to the rays is what one can best
describe as disappointing. Instead of the clear out-
hning of the bones and their cancellated structure,
a fluffy effect is seen, the outline being blurred and
the cancellus tissue difficult of detection. The
unskilled will observe " what a pity the photograph
is not clearer," and one has learnt to regard this
criticism as a strong confirmation of a diagnosis of

33

D

34

DISEASE IN BOXES

tubercular disease in joints (as well as in certain
other situations spoken of later). This blurring
is due to fluid in part, but also to thickened
synovial membrane, the fluid in the case of tubercle
being much less than in a simple acute arthritis.
An acute or subacute arthritis may_show a
greater degree of blurring than early tubercle, and
unless clinical evidence is very definite a simple and
a tubercular arthritis may be confounded. It is
not often that the mistake is made. A care-
ful examination of the surrounding bone tissue
will help to confirm or disprove a suspicion of
tubercle. On the other hand, I once examined a
child's knee much swollen and with clinical evidence
pointing to subacute arthritis after traumatism, in
which the bony surfaces were already invaded with
tubercle and the complaint really one of tubercular
arthritis of a rapid nature. In this case the rays
certainly superseded other methods of d la^nosiSj an
on their evidence the Joint was excised.

It would_bejjQCorrea_t^^^
the ndghboi£hoM_oLJo^^
t ubercle^is_simj3le_flu^^

tjie_30ifi^^effect_^^ ;
which_3r^usuall)L£as)L-Q£^detection, the^uffyjm^it

nearly alway^niean^_ti^^

stage (Fig. 23). For example, if a child complaining
of pain in a hip joint, or in some way attracting the
attention of the medical attendant and causing him
to suspect tubercular disease in this region, is

Active tubercle in tursus, an early stage

35

36 DISEASE IN BONES

examined, and one hip joint shows as clearly and
brightly as the other, the evidence is powerfully
against tubercle, and if the joint be examined again

Fic 24. -Hip joint in an active tubercular state. Note the thinning of the
bone, and the general unsatisfactory appearance from a photog.aphic
standpoint.

in a few weeks with the same result the cause of
pain, limping or what not, must be attributed to
something else.

TUBERCULAR DISEASE

87

The converse, of course, holds good, and the
careful surgeon will never omit to examine a
young person with the rays who complains of
symptoms which are in any way compatible with
hip disease (Fig. 24). In this connection I might

Fig. 25. — Congenital dislocation of right hip.

mention that congenital dislocation of the hip is
occasionally first discovered under such conditions,
and can recall at least three occasions where the
most careful of surgeons have completely over-
looked this condition (Fig. 25).

38 DISEASE IN BONES

There is no question that the symptoms of a
congenital hip are sometimes so obscure that all
ordinary methods fail to detect its presence.

The blurred or fluffy effect seen in a tuber-
cular joint is also observable in other situations ;
thus a bone shaft affected by tubercle in an
early stage gives a very similar effect. No^^doubt,
as before suggested, the fluid in the joint in a great
measure explains the obliteration of the outlines of
the joint ; burtjt is certain _that contrast aiicLjiefini-
ti£nare_jurthejL_^^

n-^mpra1_jT^^ bone Structure rendering it

less opaque. WlTatever__the__^^
i n fl^mnialiQiijjxJiOtte-seid^
graphjc_effect.

, If a piece of decalcified bone is examined with
I the ^-rays, the effect powerfully suggests a bone
affected by tubercle or in the neighbourhood of a
tubercular lesion. On the other hand, the dried
bone has much in common with the X-ray appear-
ance of osteo-arthritis.

In a later stage of tubercle in a joint, the ulcera-
tion of the joint surfaces of the bones gives rise to
irregularity in their outlining ; a more or less
ragged appearance is thus presented. This ragged
appearance is due to absorption of the mineral
matter rather than actual erosions. After this,
caries with accompanying rarefaction and tissue
destruction will markedly affect the transparency
of the bony material forming the joints. Pus

TUBERCULAll DISKASK 39

may be present at this stage, and will require

consideration.

It is a rule, and a good rule to bear in mind, so
constant that one might almost call it a law, that
radiograms of tubercular disease in bones and
joints are always disappointing from a pictorial Conjras^^^^
point of view, while osteo-arthritic conditions give
rise to photographic effects of unnatural brilHancy
and prettiness.

A tubercular cavity filled with pus may appear as
a lioht area, but not so clearly outlined as an old
cavity, such as is found in a case of healed caries.
The explanation is no doubt simple. Pus in a recent
bone cavity is accompanied by the bone debris that
has been accumulated in the interior of the cavity,
or at any rate by the mineral matter from the dis-
solved bone, and hence is much more opaque to the
X-rays than a simple fluid or medullary substance.

Added to this, the bony material forming the
walls of a tubercular cavity is poor in mineral
matter, and consequently more than usually trans-
parent to the rays. Hence the contrast is very
slight. A cavity left after a necrosis has subsided
will be more decided in outline because of the
sclerotic changes in its walls, which usually
become excessively mineralised and strengthened
by extra bony layers (Fig, lo).

The outline of a cavity the result of active
tubercular disease is irregular and eroded, whereas
the old cavity is much smoother in outline.

40

DISEASE IN BONES

It is superfluous to point out the practical
importance of these distinctions where the question
of active or quiescent disease is being considered.

When a tubercular joint has passed into the
pulpy stage, all the above-mentioned photographi-

FiG. 26.— Result of'okl tubercle. Clearness of bony tissue suggests disease

quiescent or extinct.

cally disappointing appearances are exaggerated,
the opacity of the bone becoming diminished to
the degree of extinction and the fluffy appearance
spreading and obscuring any outlines formerly
present, until it may become next to impossible to

TUBERCULAR DISEASE

41

see upon the screen the slightest trace of bony struc-
ture. Sometimes, however, the rays will reveal at
this stage a ghostly outHne of the bones. The dis-
placement which takes place in joints affected with

Fig. 27. — Result of tubercular disease between second and
third lumbar vertebrae. The clearness and density of the
bone conclusively proves the condition to be cured.

tubercle is usually discernible _with X-rays, but
in the hip, owing to the fact that radj^rams
in this region are rnostly^,jiilsati^fa£^ ar sligJit
dispkcemen^^

radiographic indication of tubercular disease, and

42

DISEASE IN BONES

in this connection the diagnostic hne which I
have described upon several occasions will be found
of great value. I append a short description.
Any interference with the symmetry of this line
should be regarded with apprehension.

Fic;. 28. — A normal hip joint showing the diagnostic line.

This line in all positions of the joint, i.e.,
abduction, adduction, etc., of the femur, is the same,
an unbroken arch formed by the top of the obtura-
tor foramen, and the inner side of the femoral neck.
Imagination must connect these two lines before a
perfect arch is formed, but a glance at Fig. 28 will

TUBERCULAR DISEASE 43

show that this hne is a reaHty and not solely
imaginative.

As before stated, in all positions ot the femur
this arch can be detected.

There are many lesions of the hip joint which
will disturb this line. Congenital dislocation is a
good example.

In Figs. 25 and 26 this broken arch is well

shown.

It is often said that the distortion of the rays
makes appearances which resemble displacements
in the hip region. To some people distortion may
be deceptive, but no amount of distortion will
affect this Hne. Anyone seeing a skiagram of a hip
for the first time, and taking into consideration the
intactness or otherwise of this line, could say with
certainty whether displacement were present or
not.

Another point is this, that radiograms of the hip
region are very often most unsatisfactory on account
of the thickness and density of the part. Few
radiograms, however bad, will fail to show the
femoral neck and the obturator foramen. Hence
in this respect the diagnosis will be as correct with
a very poor skiagram as with one in which there
is the utmost detail.

OSTEO-ARTHRITIS.

It would seem suitable to point out a few of the
important signs given by the X-rays in osteo-
arthritis as opposed to those found in a tubercular
joint. Being among the first, if not the first, to
point out the curious X-ray appearances of
rheumatoid and osteo-arthritis to the X-rays
{Clinical 'journal^ May 29th, 1901), my attention
has been drawn to the subject for many years, and
though there is " a look " about an osteo-arthritic
joint v/hich to the experienced eye is unmistakable,
it is with difficulty that 1 am able to determine
upon facts which will serve as guides to the
diagnostician. Tubercle is the most likely disease
to be mistaken for osteo-arthritis.

In the first place, the characteristic which these
two diseases have in common — a thinning of the
mineral matter — is, paradoxically, the most im-
portant factor in their differentiation.

The thinning of the mineral matter in the
bones of tubercular arthritis is of such a general
character that perhaps the best simile would be a

OSTEO-AKTHRITIS 45

chalk drawing very much " rubbed out "—a blurred
faint image. Hence a characteristic radiogram of
a tubercular joint is a disappointing one from a
pictorial standpoint.

" Mr. So-and-so would be glad if you could get
him a clearer radiogram of such-and-such a joint "
has been said to me so often in relation to tubercle
that I am bound to admit my indebtedness to Mr.
So-and-so for pointing out an indisputable fact —
which he has failed to recognise himself— that
the general ^-ray characteristic of tubercular
joint disease is want of contrast and want of
detail.

Turning to rheumatoid and osteo-arthritis (I D^^^'e"-
cannot find any J^-ray line of demarcation for diagnosis,
these diseases, and so will speak of them as if
varieties of the same), a thinning mineral matter is
most noticeable, but of a totally different nature
from a tubercular thinning.

Certain portions only of the bone are thinned,
and in such a way as to produce an outlined effect,
not only of the bones, but of their internal
structure. I would suggest, as simile, the skeleton
leaf. The result of this special form of absorption
oJ_jh£__jTmieral__^^ increase detail and

strengthen the outline of the ^ITotogi^aphjc^image
(Figs. 29 and 30). In other v^ords, the radiogram
is, from a pictorial aspect, prettier than normal.

To summarise, the tubercular joint gives a
radiogram of a disappointing fluffy and ill-defined

46

48

DISEASE IN BONES

appearance, while the osteo-arthritic joint gives a
particularly brilliant one. I cannot say that every
case will present these characteristics to such a
marked degree that no one could err in a diagnosis.
But I will confidently affirm that in a greater
or lesser degree they are always present.

Though I am making a rule to confine my
remarks to the general characteristics of bone disease,
I venture here to break this rule by giving details
of a case. I do not publish the radiograms because
they are not entirely typical, and I fear in
reproduction they might appear in a misleading
form.

Dr. Winslow Hall has most kindly furnished
most of the details which I append.

On June 2nd, 1908, I was called to see a
patient who was suffering from a swollen knee.
Patient, elderly unmarried lady. Family history,
markedly tubercular.

Oct. 4th — Slipped on fallen leaf, and fell on her
knee.

Oct. 5th-7th. — Rest.
Oct. 8th-26th. — At work (teaching).
Oct. 26th to Nov. loth. — Rest and "Bier"
treatment.

Nov. 19th to Dec. 1 6th. — At work wearing
bandage. Calmette's test gave positive result.

Dec. 19th. — Seen by Surgeon "A."

Dec. 23rd. — Opsonic indices before Bier's
bandages 1-03. After two hours, r20.

OSTEOARTHRITIS

49

1909, Feb. 27th. — Bier's bandages two hours
once a week.

March 12. — Fluctuation in joint.

April 7th. — " A " sees patient, advises amputa-
tion, but tuberculin to be tried first.

April 9th to May 21st. — Four injections of
tuberculin fortnightly.

June 2nd. — X-rays and diagnosis of osteo-
arthritis.

June iith. — Opsonic indices before Bier's
bandages i*c8. After, i-qi.

June 26th. — Another surgeon, hereinafter called
" B," advised operation — " politeal space full of
pus."

June 29th. — -Aspirated fluid examined. No
pus, no organisms.

Case then seen by another medical man, " C,"
a relation, who agreed in rejecting diagnosis of
tubercle and amputation. Treatment by Scott's
dressing, and pot. iod. in large doses, then Thomas'
knee splint, then crutches. Steady improvement
until 1909, when walking on own feet, wearing a
poroplastic case round knee, and using stick and
crutch.

July-October. — Away in Ireland ; on return
amputation demanded by patient, and performed
by "A."

I make a few extracts from a letter sent
me on October 7th, 1909, by Dr. Winslow
Hall :—

E

50

DISEASE IN BONES

" Dear Sir,

" Probably you have not forgotten that knee

of Miss , which you radiographed for me last

summer. The sequel will interest you."

Here follow a few details unimportant to the
subject in hand, and Dr. Winslow Hall con-
tinues :

" When she returned, he (' C ') wrote to me
strongly urging amputation, on account of her
confirmed and increasing invalidism. She herself
desired amputation, and her relatives also urged it.

" I pointed out that the joint had been steadily
improving, and that a useful limb could be counted
on in time. I maintained that the limb, as a limb,
did not require removal, but that possibly she
might require removal from her limb.

" ' A ' was asked to see her again. He promptly
advised amputation. Accordingly he did a supra-
condylar amputation yesterday. The joint showed
no sign of tubercular disease, but was typically
osteo-arthritic with very thick growing ligaments
and considerable eburnation of cartilage and
bone.

" If you care to see the specimen, you will find
it at X, Y, Z Hospital. You see you were quite
right. Other comment is needless."

Looking back over the history of this case,
certain facts stand out vividly. The great surgical
opinions, so positive and so wrong ; the convincing
circumstantial evidence in favour of tubercle ; the
whole so biasing to the newcomer that it needed
much courage and faith to uphold what seemed an

OSTEOARTHRITIS

51

impossible theory, the theory of osteo-arthritis as
divulged by the X-rays ; the instinctive leaning
towards this theory of the patient's medical

Fig. 31. — Osteo-arthritis of knee, showing the typical outhning and

fine definition.

attendant, Dr. Winslow Hall, before and after
X-ray examination.

I have recently read Dr. Llewellyn Jones' able
book on " Arthritis Deformans," and I would

E 2

53

33. — Atrophic change in bone caused possilily by old fracture of patellee.
The change is not unlii<e osteo-arthritis in many respects.

53

54

DISEASE IN BONES

No line of licsitate to add to the literature of this subject which

demaica-

t'o" is ah'eady so extensive and comphcated. So much

between -'

osteoand confusion would apocar to exist in the differential

men ma- ^ -T

Ivlhiitis diagnosis of osteo and rheumatoid arthritis that it
may be of interest to state as the outcome of
one's X-ray experience, no line of demarcation
exists, nor does one find any X-ray evidence to
support the idea that there are two definite and
dissimilar diseases.

Whether this condition is one disease with a
multiplicity of clinical and physical signs or
whether a multiplicity of diseases, the rays do
not seem able to determine, but one would be
inclined to think that there is one general X-ray
characteristic, that of the peculiar thinning above
described, and two particular J^-ray characteristics,
that of a ycry marked thinning in certain regions
as in the phalangeal joints ^of the hand (see
Figs. 29 and 30), and that of additional bony
tj£su^_cajismgjjpping^ (Fig- 3^)-

Thinning Unquestionably the former, the marked local thin-

usuallv . . , . • 1 1

means nin? as in all bone disease, indicates a rapid and

active

disease, activc process or disease (Fig. 31), and the latter
a very old-standing and usually quiescent condition
(Fig. 32). By quiescent I mean no active inflam-
matory process though mechanical conditions may
be getting progressively worse for mechanical
reasons.

I show Fig. 32 as what I consider a typical
example of this latter condition.

I' lc;. 34. — Atrophic changes in bone of amputation stump. ;

55

56 DISEASE IN BONES

Other atrophic changes in bone are often
observable round about old badly united or un-
united fractures. Fig. 33 shows this condition,
which would certainly in my opinion negative any
operation on these bones. They would be too
friable in their present condition.

In Fig. 34 atrophic changes of a local nature
are taking place in an amputation stump.

GROWTH IN BONE

Non-malignant.

These are either cystic in nature, simple or
parasitic, and evident to the rays as hollow cavities
of regular outline, unlike the usually ragged
appearance of abscess cavity, or they are over-
growths of the normal tissues forming bone.

Exostosis is an example of the latter, and one Exostosis,
of the easiest of all abnormal bone conditions to
diagnose. These out-growths usually appear as
hook-like processes, and when such a hooked
protrusion from the bone is noticed in a region
which is a common site of exostosis, no trouble
will be found in deciding the nature of the
disease.

This apparent hook, which merely indicates the
arrangement of the bone salts and does not neces-
sarily imply a real hooked process capable of being
felt externally, invariably turns away from the
epiphysial line nearest to which it grows
(Figs. 35 and 36).

57

58

DISEASE IN BONES

There is, however, an occasional specimen of large
exostosis which might possibly suggest a sarcoma
of slow growth — that is, one that is ossifying as
it grows (Fig. 37). Usually the clinical signs are

Fig. 35. — Typical appearance of exostosis. The hook turns away from

the epiphysial line.

such that no question arises as to its innocence,
but should there be any doubt a careful exam-
ination of the radiographic appearance will
decide.

Fig. 36. — Exostosis of head of fibula accompanied by some
enlargement of the head of that bone. The possibility of
malignant disease had to be considered in this case, and the
X-rays proved the innocence of the condition. The hook-
like process turning away from the end of the bone is veiy
characteristic of exostosis.

Fig. 37. — Exostosis simulating clinically periosteal sarcoma of
upper end of humerus.

60

61

Fig. 39.— Sarcoma of lower end of fomiir. The new bone deposited around
has an irregular spotty appearance totally different from the regular
layers seen in chronic periostitis. (Mr. Mower White's case.)

64

DISEASE IN BONES

In exostosis the_growth is slow and regulac^anH
the resulting radiogram shows tins to perfectioji,
just as the section of a tree trunk shows by its
rings the uniformity and regularity of its growth
Maiig- (Fig. 38). Innialignanc)^_t^

nancy. , . ] " ' '

place in a ragged and_i^rregular way, and tlTe_effect
is spotted and notjiniform^ It is often that small
patches are__breaking down, ajid^these, appearing
lighter^Tan surrounding parts^jidd to the hetero-
geneous arrangem£nt_jif__the_^^

This irregularity i^_jn_eve0__form of bone
malignancy a prominent feature.

I would here pause to consider a case of
endosteal sarcoma where a disregard of this spotty,
irregular appearance led me to suggest that the
condition was a simple one. Mr. Mower White,
who had the case under his care, fortunately did
not agree, and he removed the limb with complete
success. This case made a great impression on
me, and I hope it has been the means of forcing me
to notice the really vast difference in the radio-
graphic effects between simple inflammatory
conditions and malignancy.

Radiograms of this case betore operation are
here shown (Figs. 39 and 40), as well as one taken of
the bone above just after removal (Fig. 41). In
the latter case the irregular blotchy nature is more
easily recognisable.

The disease was sarcoma, and all the bony
substance was involved. There was much ossifica-

#

'■ 41;— Sarcoma, the actual bone from case shown in
I^igs. 7 and 8. (Mr. Mower White's case.)

05

F

Fu;. 43. — Endosteal sarcoma in child. Note tlie irregular spoUy appearance.

68

DISEASE IN BONES

tion going on, accompanied by a breaking-down
process.

If this appearance were committed to memory
it would be found a landmark when investigating
bone disease. As disappointment in photographic
result means tubercle, and brilliancy in contrast
means osteo-arthritis, so gross irregularity in the
substance of a bony growth means malignancy.
Rules are but rules and subject to exceptions, but as
rules these observations are of value.

An endosteal malignant growth is usually easier
to detect than a periosteal. The obviously rapid
expansion of the overlying bony shell is apparent,
and could not be mistaken for an inflammatory
condition. The medullary cavity disappears, and
the only bony material is that on the outside of
the swelling. Fig. 42 shows an endosteal sarcoma
of radius.

This case was sent to me as a greenstick fracture
of radius with much callus formation. Comment
is superfluous.

OSTEO-MALACIA

Typical examples of this disease are shown in
Figs. 44 and45; here may be seen the replacementof
the medullary tissue by X-ray transparent material,
and the general rarefaction and absorption ; the
centrifugal method of progress, and the immunity
(more or less) of the compact tissue.

Fig. 44. — Osleo-inalacia, showing the rarefaction acconipanieil by
new deposit of bone in neighbourhood of compact tissue. The
bone would appear to be strong on account of the density of the
mineral matter.

70

Fig. 45. — Side view of Fig. 44, showing where disease leaves off and fairly normal

bone begins.

71

72